Opting in and Opting out of Medicare

OPTING IN AND OPTING OUT OF MEDICARE

This question comes up repeatedly on our listservs: Am I in violation of Medicare regulations if I see Medicare beneficiaries as self-pay patients, collect from them directly, and do not enroll in Medicare?

According to Laura Groshong, LICSW, of the Clinical Social Work Association, the answer is yes, unless you opt out:

“All LCSWs are required by CMS to opt-in or opt-out of being a Medicare Provider. Though all LCSWs are eligible to be a Medicare provider, until an LCSW “opts in”, the LCSW cannot be reimbursed by Medicare. Technically, if a Medicare beneficiary wants to be treated by an LCSW and the LCSW has not opted out, the LCSW is liable for sanction. If an LCSW has opted-in to Medicare as a provider, the LCSW is responsible for seeing or providing a referral for every beneficiary who want[s] the LCSW’s services. Any LCSW who remains in ‘limbo’ as not opted- in or opted-out can potentially be sanctioned by CMS if a complaint is filed.”

Members should inform themselves about Medicare regulations to fully protect themselves.

If you see no Medicare patients and have never enrolled as a Medicare Provider, you do not need to enroll or opt out if you do not intend to see any Medicare beneficiaries in the future. But keep in mind that patient populations are aging and that you may soon have to address this question in your practice. And remember that Medicare covers not only persons over 65 but disabled persons on Social Security Disability (eligible for Medicare two years after enrolling in SSD).

To enroll as a Medicare Provider go to: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/index.html

If you are enrolled but no longer wish to be a Medicare Provider, for whatever reason, you need to opt out by sending a letter to National Government Services. Retain a copy in each Medicare patient’s file. To obtain the affidavit for opting out go to: https://www.ngsmedicare.com/ngs/wcm/connect/7e59fd93-6fd6-4fa4-a453- 7536ef269b86/392_0414_Medicare_Opt_Out_Affidavit_508.pdf?MOD=AJPERES

Once you have opted out you need to have a written agreement with any Medicare patient in your practice. The agreement will state that you will not be able to bill Medicare and that the patient will be unable to bill Medicare and be reimbursed. If you have opted out, the law states you must renew the opt-out every two years.

If you have been a Medicare provider but have not billed Medicare for over one year you will be de-activated and will have to re-enroll to regain active status in order to officially opt out.

All clinical social workers are considered providers of Medicare by CMS. According to the CMS Operating Manual they must accept assignment and must accept the Medicare allowed charge as payment in full. This was stipulated many years ago when Medicare agreed to approve clinical social workers for third party payment. (It was also stipulated at that time that we would receive 75%of the contracted fee for psychiatrists.)

Bizarre though some Medicare regulations seem, this is the best information we have.

Helen T. Hoffman, LCSW, Chair, Vendorship and Managed Care Committee

October 26, 2015